EP Lab Digest - May 2008 - (Page 26)

26 EP APPROACH MAY 2008 Alcohol Septal Ablation in the Cath Lab: What is it All About? Visali Kodali, MD,Todd Cohen, MD, Srihari S. Naidu, MD Division of Cardiology, Department of Medicine Winthrop University Hospital Mineola, New York The patient was a good candidate for alcohol septal ablation (ASA) of the hypertrophied septum based on his cardiac anatomy, hemodynamics, and persistent clinical symptomatology, despite maximal medical therapy. anterior motion (SAM) of the anterior mitral valve leaflet, mild mitral regurgitation, and a provocable subaortic gradient of 120 mmHg (Figure 2). The patient was a good candidate for alcohol septal ablation (ASA) of the hypertrophied septum based on his cardiac anatomy, hemodynamics, and persistent clinical symptomatology, despite maximal medical therapy. Under full heparin anticoagulation and temporary transvenous pacemaker placement, a guide catheter was advanced to the left main coronary artery, and the first septal artery was selected and wired using standard angioplasty technique. A 2.0 X 9 mm over-the-wire angioplasty balloon was advanced and positioned immediately distal to the ostium of the first septal artery, and inflated so as to obstruct blood flow into the artery.After removing the wire, 3 cc of 98% ethanol was infused slowly through the balloon central lumen under vigilant fluoroscopic guidance, with resultant ablation of the septal tissue (Figure 3). Transthoracic echocardiographic guidance was utilized to guide therapy. A successful result was obtained, with >50% immediate reduction in the provocable subaortic gradient, and the procedure was terminated. Over the ensuing six months, the patient reported NYHA class I symptoms of dyspnea only on maximal exertion. Furthermore, he has been able to reduce his medication regimen in half. blative therapy has been a staple of electrophysiology for years and a major treatment modality for various rhythm disorders. Indeed, the advent of radiofrequency ablative therapy has ushered in a plethora of curative solutions for some of the most complex rhythm disorders, including atrial fibrillation and flutter,AV nodal re-entrant tachycardia, accessory pathway mediated reciprocating tachycardia, and most recently, ventricular tachycardia. Over the past few years, a novel form of ablation that utilizes 98% ethanol has been utilized in the cardiac catheterization laboratory to treat severely symptomatic patients with hypertrophic obstructive cardiomyopathy. Performed by interventional cardiologists, the technique has become an increasingly utilized method to improve quality of life in these debilitated patients. A Discussion Hypertrophic cardiomyopathy (HCM) is defined as hypertrophy of the ventricular myocardium disproportionate to any accompanying hemodynamic load. It is usually asymmetric and most commonly involves the interventricular septum. About 25% of HCM cases are associated with dynamic left ventricular outflow tract (LVOT) obstruction from the hypertrophied septum and opposing systolic anterior motion (SAM), and are termed hypertrophic obstructive cardiomyopathy (HOCM).32 Typically the hypertrophic myocardium is poorly See ALCOHOL SEPTAL ABLATION page 28 Case Presentation A 65-year-old man with hypertension, hypercholesterolemia, benign prostatic hyperplasia and hypertrophic obstructive cardiomyopathy presented to our facility with NYHA class III symptoms of dyspnea and chest tightness with minimal exertion. He denied syncope, lightheadedness or palpitations. Despite aggressive medical treatment with a high-dose beta blocker and calcium channel blocker (metoprolol 300 mg per day and diltiazem 180 mg per day), his symptoms continued to progress. Physical exam revealed a 2/6 systolic ejection murmur at the upper left sternal border, which was accentuated with Valsalva maneuver and diminished with hand-grip. The remainder of his physical exam was unremarkable. Electrocardiogram revealed normal sinus rhythm with right bundle branch block, left ventricular hypertrophy, left atrial enlargement and Q waves in leads II, III and AVF (Figure 1). On echocardiogram, there was asymmetric septal hypertrophy (septal thickness 1.9 cm, posterior wall 0.9 cm), systolic Figure 1. The electrocardiogram reveals normal sinus rhythm with left ventricular hypertrophy, left atrial enlargement and Q waves in leads II, III and aVF.

Table of Contents Feed for the Digital Edition of EP Lab Digest - May 2008

EP Lab Digest - May 2008 Is There an Under-Referral of Women for Atrial Fibrillation Ablation? A Hybrid Approach to the Cure of Atrial Fibrillation Contents Letter from the Editor Spotlight Interview: University of Michigan Health System 10-Minute Interview: Amit J. Shanker, MD Modular EP Units: Are They Possible? One Hospital’s Experience All About My Job: Technician Supervisor (New Column!) Alcohol Septal Ablation in the Cath Lab: What is it All About? About the Canadian Heart Rhythm Society: Interview with Martin J. Gardner, MD, FRCP(C), FACC Email Discussion Group: May 2008 Second Annual Salary Survey My First Year in Electrophysiology: What Have I Got Myself Into? Highlight on Technology: Video-Audio Integration for the EP Lab On the Horizon: A New Remote Catheter Manipulation System Striving for Excellence in the Care of Cardiac Patients Five Reasons to Participate with a Professional Organization Suspected Shunting of Defibrillation Energy in the EP Lab Can Digital Music Players Cause Interference with Implantable Devices? ECG 101: Ambulatory ECG Monitoring Events Calendar Industry News and Products Classifieds Advertisers Index

EP Lab Digest - May 2008

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